Sheri Fink's first book, War Hospital: A True Story of Surgery and Survival, followed medical professionals under siege during the genocide in Srebrenica, Bosnia-Herzegovina.

Jen Dessinger

On Aug. 30, 2005, a doctor climbed the stairs through a New Orleans hospital to the helipad, which was rarely used, and so old and rusted it wasn't even painted with the hospital's current name.

From that helipad over Memorial Medical Center, the doctor looked out over New Orleans, now flooding after Hurricane Katrina. He considered the more than 2,000 people in the hospital below — 244 of them patients.

Administrators had long-standing plans to manage hurricanes, flooding, loss of electricity and evacuations, but they weren't prepared to deal with them all at once, which is what the hospital faced during Katrina.

The staff had to decide who to save, and in a new book, Five Days at Memorial, writer and physician Sheri Fink reconstructs the choices they made. She tells NPR's Steve Inskeep about the sickest-last evacuation system they put in place, and how some doctors hastened their patients' deaths.

Interview Highlights

On what happened when hospital staff realized they were going to lose all backup power

"That's when the very first tough ethical decision arose ... which was: Who are you going to save first if you know that you may be hours away from all power going out? ...

"They decided that the babies would be saved first, and the intensive care unit patients, whose lives really depended on electricity. They also decided at that point who would go last, and that was patients who had do not resuscitate orders.

"The doctors all agreed with this decision and, by the way, it was a small group of doctors who took this burden of making this decision on their shoulders."

On why Memorial doctors decided that the sickest would be evacuated last

"As one doctor described it ... they would maybe have the least to lose compared with other patients. ...

"Doctors tend to be — and this is, some ethicists have explained this to me — doctors have kind of a utilitarian frame. If you ask them, 'Who gets the organ transplant?' it's going to be the person who they think could benefit the most from it, and other considerations might not be taken into account, like justice or fairness. ... So you're switching, in a disaster, sometimes from looking at what doctors normally are supposed to do, which is treat each individual patient to the max, to this more population-based approach."

On how Memorial doctors began hastening their patients' deaths

"At some point on the day that the power failed, a few hours after that, some of the doctors told me that they walked around the hospital, had a look at the situation of the patients and felt that hastening death was the right choice.

"You know, one of them had gone upstairs to the intensive care unit where there was just one patient left. Most of them had been taken out first, but she was very, very sick. She had this do not resuscitate order and had been held back. And he asked the nurse, 'Give her enough morphine till she goes.'

"The other doctor [John Thiele] actually was involved in injecting some of those patients on that Thursday, Sept. 1 of that year. ... And he also told me that the intent was to let these people die. He did describe to me having a moment after he did these acts where he did wonder whether it was the right thing. And he even hesitated just before he started injecting the patients and he asked the woman next to him, a nurse who was on the ethics committee, whether they could really do this.

"Now, one thing he didn't consider was staying there with the patients until they died."

On whether other hospitals are likely to face the same challenges Memorial faced during Katrina

"I saw it last year with [Superstorm] Sandy. After everything we should have learned from Katrina, we saw hospitals lose power, hospitals being evacuated in the middle of a hurricane, ICU babies taken out by hand down darkened staircases, hospitals that knew that they had vulnerabilities not evacuating in advance.

"We can't just say, you know, the government failed, the corporation failed. That's the easy way out. Yes, they have to do better, we have to do better. But then there's also this really important role, and I've seen it over and over again in every disaster or conflict zone where I've worked, that individual decisions can have a large and reverberating impact. There is a tomorrow after a disaster, and it's sometimes hard to remember that in the midst of it."

Copyright 2013 NPR. To see more, visit http://www.npr.org/.

Transcript

RENEE MONTAGNE, HOST:

It's MORNING EDITION, from NPR News. I'm Renee Montagne.

STEVE INSKEEP, HOST:

And I'm Steve Inskeep, good morning. On Aug. 30, 2005, a doctor climbed the stairs through a New Orleans hospital. He arrived at the hospital helipad, which was rarely used; so old and rusted, it wasn't even painted with the hospital's current name. From that helipad over Memorial Medical Center, the doctor looked out over New Orleans neighborhoods, which were flooding after Hurricane Katrina. He considered the more than 2,000 people in the hospital below - 244 of them patients, many of them seriously ill.

MONTAGNE: A new book reconstructs the excruciating decisions that were made inside the hospital below that doctor's feet. The book is called "Five Days at Memorial." Writer and physician Sheri Fink spoke with many people who were in the hospital in those days. She reports that administrators had longstanding plans to manage hurricanes - flooding, loss of electricity and evacuations - just not all at once.

INSKEEP: Which is exactly what the hospital faced when it became clear that flooding would disable the backup power generators.

DR. SHERI FINK: That's when the very first tough ethical decision arose.

INSKEEP: Which was?

FINK: Which was: Who are you going to save first, if you know that you may be hours away from all power going out?

INSKEEP: What decision did they make?

FINK: So they decided that the babies would be saved first; and the intensive-care unit patients, whose lives really depended on electricity. They also decided, at that point, who would go last. And that was patients who had "do not resuscitate" orders. The doctors all agreed with this decision. And by the way, it was a small group of doctors who took this burden of making this decision on their shoulders.

INSKEEP: Very early on in the book, you've got a line here where you say there are people who are in a room; in a dark room, a powerless room. They've got tags on them indicating the order in which they'll be taken to a helicopter. And you write that doctors had decided "that these sickest individuals in the hospital were to be evacuated last." And when I read that, Sheri Fink, I had to stop and read it again and a third time, because I thought I'd gotten the sentence inverted somehow.

FINK: Yes.

INSKEEP: What was the reason that the sickest would go last?

FINK: That - well, as one doctor described it, that they would maybe have the least to lose, compared with other patients; that perhaps they might not be able to save everybody and so at least this way - I guess the, you know...

INSKEEP: Don't go to the trouble of saving someone who might die very soon anyway, or even die during the rescue. Go for someone who has a better chance to survive.

FINK: Yeah. I mean, the way this is looked at - and it's really debated, and I'm not surprised you had the reaction you did. I think a lot of people would, which is why we need to talk about this because doctors tend to be - and this is, some ethicists have explained this to me - doctors have kind of a utilitarian frame. If you ask them who gets the organ transplant, it's going to be the person who they think could benefit the most from it. And other considerations might not be taken into account, like justice or fairness. So you're switching, in a disaster, sometimes, from looking at what doctors normally are supposed to do - which is treat each individual patient to the max, to this more population-based approach.

FINK: So at some point on the day that the power failed - a few hours after that - some of the doctors told me that they walked around the hospital, had a look at - what the situation of the patients, and felt that hastening death was the right choice. You know, one of them had gone upstairs to the intensive care unit, where there was just one patient left. Most of them had been taken out first, but she was very, very sick. She had this do-not-resuscitate order and had been held back. And he asked the nurse, give her enough morphine until she goes. The other doctor actually was involved in injecting some of those patients on that Thursday, September 1st of that year.

INSKEEP: John Thiele - is this the man we're talking about?

FINK: Yes, John Thiele. And he also told me that the intent was to let these people die. He did describe to me having a moment after he did these acts where he did wonder whether it was the right thing. And he even hesitated just before he started injecting the patients. And he asked the women next to him - a nurse who was on the ethics committee - whether they could really do this.

Now, one thing he didn't consider was staying there with the patients until they died, or trying to go out and see whether they could bring in some new medical staff. I mean, there's this blindness that comes in, in a disaster; this - you know, the real key for people who are seasoned disaster responders, they know. It's just like the military; like, you have a plan but then you have to be prepared to change that plan. So it's preparation, but it's also flexibility. And that's so hard to do, but that's why - I mean, my hope is that we can all think about these things in advance.

INSKEEP: You hope people will think about these things in advance. Do you think it is likely that the doctors and patients of some other hospital in the United States are going to face similar choices again, before too long?

FINK: I do feel that way because I've seen it. I saw it last year with Hurricane Sandy. After everything we should have learned from Katrina, we saw hospitals lose power, hospitals being evacuated in the middle of a hurricane, ICU babies taken out by hand, down darkened staircases, hospitals that knew that they had vulnerabilities not evacuating in advance.

We can't just say, you know, the government failed; the corporation failed. That's the easy way out. Yes, they have to do better; we have to do better. But then there's also this really important role - and I've seen it over and over again, in every disaster or conflict zone where I've worked - that individual decisions can have a large and reverberating impact. There is a tomorrow after a disaster, and it's sometimes hard to remember that in the midst of it.

INSKEEP: Sheri Fink is the author of "Five Days at Memorial." Thanks very much.